The final episode of the show House, MD airs on FOX tonite. I wrote the following op-ed piece for USA Today; it’ll appear there tomorrow morning and is reproduced here with permission.

Dr. Gregory House hung up his stethoscope and cane for the last time last night and shuffled off into eternal life in the Land of Reruns. House — the brilliant, misanthropic, drug addicted, my-way-or-the-highway physician — has been an entertaining presence on FOX television for the past eight years. I enjoyed the series and even learned a little medicine. I also took some pride in the show, since House was television’s first hospitalist, a term I helped coin and now the fastest-growing specialty in modern medicine.

But as entertaining as he was, House was a throwback to an era in which the antisocial tendencies of some physicians were seen as irrelevant to their doctoring. As medical leaders strive to redefine “the great doctor” of today, House’s departure is both timely and welcome.

When I went to medical school in the 1980s, many of us valued nothing more than our autonomy. We saw medicine as an individual, not a team, sport, and interpreted professionalism as unwavering advocacy for our patients. While this was often healthy and noble, in some cases it crossed the line into obnoxiousness, even rage. (Today, we call doctors who cross this line “disruptive physicians.” Dr. House would certainly qualify.)

Hospitals were co-dependent. All too aware of their heavy reliance on the physicians’ control over their revenue stream, hospital administrators learned to coddle doctors, with everything from prime parking spots to a personalized menu of surgical equipment. This kept the doctors happy, but also led to wildly expensive and sometimes risky variations in practice, even within the same institution.

This reliance also made everyone tiptoe around the dysfunctional behaviors that Dr. House so memorably illustrated each week. In one survey of more than 700 nurses, 96% reported seeing doctors engaging in disruptive behavior, and almost half pointed to fear of retribution as the reason such acts went unreported. Another survey found that one in four doctors and nurses believe that disruptive behaviors are associated with preventable deaths. I agree, having seen cases of medical errors in which a scrub nurse or physician trainee suspected that a senior doctor was about to commit a terrible error, but kept quiet rather than risk the physician’s ire.

Former secretary of State Henry Kissinger once observed that “weakness is provocative.” When it comes to taking decisive steps to address the problem of disruptive doctors, we have been both weak and provocative. The reasons are several and knotty. We doctors are not schooled in managing confrontation, and we’re particularly timid when asked to judge the behaviors of our colleagues under our system of “peer review.” Moreover, we worry about being sued if we act decisively against another physician.

But another reason goes to the heart of House’s widespread appeal: patients seem to believe that the Gregory Houses of the world must have terrific clinical skills, whether in performing brain surgery or diagnosing a rare case of strongyloidiasis. While Dr. House did have Sherlock Holmesian diagnostic acumen, the insider’s secret is this: great doctors are skilled at both medicine and teamwork. Patients shouldn’t have to choose one or the other.

Spurred by the patient safety movement, the medical community is finally taking steps to address the problem of antisocial doctors. Gerald Hickson, MD, of Vanderbilt has created a program that begins with a “cup-of-coffee conversation” but escalates to the loss of hospital privileges for physicians who fail to respond to education and counseling. In my own hospital, we have dismissed several physicians over the past few years for behavior that I’m certain would have been tolerated a generation ago. These are wrenching decisions, but ultimately correct ones.

While we’re getting better, we are still not where we need to be. Hospital peer review committees are only partially shielded from lawsuits, which creates a chilling effect. Options for counseling aimed at improving the behavior of disruptive doctors are limited. And doctors released from one hospital for behavioral problems are generally able to continue practicing in other settings, even if their behavior hasn’t changed.

Over the past decade, we have come to realize that, for all its miracles, the American health care system produces uneven, error-prone, and backbreakingly expensive care. These problems are complex and require an array of solutions, ranging from computerization to standardization, from simulation training to patient engagement. But we also need physicians who are smart, well-trained, innovative, intensely focused on delivering the best care to their patients, and who can play well with others. While House had many of these skills, the teamwork part was his fatal flaw. If he worked for me, I would have fired him, somewhere around Season Three.

So rest in peace, Dr. House. Thanks for being in our lives for these past eight years.

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16 Responses to “Gregory House, MD, RIP”

I like your take on disruptive doctors. You recommend solutions to error prone hospitals “ranging from computerization to standardization…”

Might there be a new term, disruptive infrastructure? Or even better yet, a term disruptive administrators for those who take down seven figure compensation while their hospitals are not particularly safe?

Yet, and so timely for your report, here we go, another monitor story in an ICU that handles huge numbers of open heart surgery cases; according to the Pennsylvania Health Care Cost Containment Council, some of the highest in the state.

How would computerization have helped this poor patient when the care was already highly wired according to HIMSS accolades? Might, just might, the distractions caused by the EHR and CPOE systems have been the trigger?

I’m curious if anyone could provide cases of behavior from physicians that would have been tolerated a couple years ago, but is not tolerated now and they are dismissed from the hospital. I’m asking because I’m a journalist looking into this matter and do not think it is a good idea to decrease physician supply.

Great piece, Dr. Wachter. I grew tired of the show and the character… he’s a drug addict, but he’s talented. He’s misanthropic, but boy we sure need him.

As somebody who was an outsider to healthcare seven years ago (from an engineering background), I was blown away by the disruptive behavior that was reported and tolerated in hospitals… behavior that wouldn’t be tolerated and excused in most workplaces.

You say hospitals “were” dependent on physicians for their revenue stream… I think that’s still often true in the current tense.

As more hospitals embrace the “lean” management methodology, they learn that one of the two pillars, from Toyota, is “respect for people” — and how that mutual respect is required to have an environment of safety and quality. It will be interesting to see how healthcare reconciles the old mindsets with the new mindsets of lean and the modern patient safety movement.

Really appreciated your comments, Mark, along with Dr. Wachter’s initial piece…as well as others in this blog talking about disruptive behaviors of professionals. In our recent research study of over 400 leaders dealing with toxic, uncivil behaviors, 94% of leaders have had to deal with this. Consider the fact that 30.7% of nurses who are targets of incivility quit; 60-80% of the medication errors are due to the disruptive behaviors of professionals. Our research (with Dr. Elizabeth Holloway) discovered 3 types of toxic behaviors: shaming, passive hostility, and team sabotage.

I am impressed with the Joint Commission’s addressing of this in advocating for a process for dealing with behaviors of professionals impacting patient safety. Our recent book, “Toxic Workplace: Managing Toxic Personalities and Their Systems of Power” provides more data on the impact of these behaviors.

It’s fascinating to me that in the work I do with healthcare systems, this is a behavior whose time has come. It makes common sense (but is far from common in having a system for dealing with this). We found a 3-point system of organizational, team, and individual interventions. And these need to be both proactive and reactive.

We are all concerned with patient safety. Sometimes we look in all the wrong places to address this. Establishing healthcare communities of what we call “everyday civility” is one whose time has come.

I sincerely appreciated the thoughts in this blog. Thank you, Dr. Wachter, for initiating this.

I admire your forebearance in waiting until season three. I would have fired him after the first episode. I graduated from medical school in 1975 (wow! 37 years ago), and have seen the “angry young doctor” type (originally portrayed as Ben Casey) come and go, always thankful when they go.

Having done hospice and palliative medicine for the past 20 years, I am convinced in the value of a properly supported team, a concept lost completely on House, as well as a number of other physicians I know.

I don’t know House was the character we loved to hate or hated to love. All I know is that I’m grateful for the physicians who blend diligence and excellence with humility and kindness. Yes, RIP Gregory House and Long live Bob Wachters of our world.

Haven’t we all secretly wanted to respond to the occasional patient as “House” did routinely? Happily most of us don’t – he allowed comic relief. AMF Dr. House! (you know what this means at least if you were around BCH in the 70’s)

Thanks Bob for your topic. I watched a few minutes of “House” when it first went on the air and it was because of that “disruptive behavior, ” especially to nurses that I never watched it again. It is SAD that the public embraced his character and the show. Perhaps it was good writing and interesting TV, but to give that type of arrogant, medical hubris a platform is wrong in today’s milieu of increased interprofessional collaboration and intolerance to medical bullies, not to mention the pursuit to mitigating medical safety errors. I’m glad to see you’re on out side. More Americans, health care workers, and colleagues need to see the light. Some medical centers are exemplary, but still others are decades behind. And as one person noted, it is true that organizations and their managers are to blame as well. Thanks, as always, for your insightful blog.

Congratulations Dr. Wachter:
You have joined the ranks of the bureaucrats. You have the luxury of time to watch a television version of a physician’s life and actually believe that there is a semblance of reality in the characters it portrays.
I must admit that I do not have the luxury of time to allow me to pop a Bud and watch the antics of my fictionalized peers.
More relevant are the questions that are posed below.
How often are you awakened by a functionary demanding that you clarify whether the patient you admitted is “observation” or “inpatient”?
Were you ever asked to justify whether the protein pump inhibitor that had controlled your patient’s symptoms was appropriate and then fill a questionnaire or call 1-800-YOU-JERK and talk to a computer to justify your decision?
How often are you awakened by some ignoramus at midnight informing you that your patient had “trace proteinuria” and ask how you would treat it?
Any angry response from the recipients of such abuse would condemn them by your standards to the dog “house”
Unfortunately, the dogs in the trenches are demeaned and castigated by the Gods from Mount Parnassuus.
Even the Gods have clay feet.

Well then, a very good summary with good ideas but I disagree about disruptive physicians. Physicians sound bossy when they are scared and they seem disruptive to those who do not want to hear what they say. Take for example the first commenter on the ICU catastrophe at the famous transplant center of the world, UPMC, with its $6 million/year CEO, for a doctor to tell what happened (and I am sure they do know), they would be sham peer reviewed on the orders of so called leaders who find the truth disruptive. What seems to have happened there is criminal and merits more than a lawsuit. The DA ought to investigate.

I like your take on the disruptive physcian. We all have unfortunately experienced this behavior far too often. I worry about the “Team Work” your are advocating. It sure sounds delightful and is the politically correct answer to our health care quality and care delivery problems.
So why the “team” clicks the appropriate boxes in the EMR, huddles to ensure communication and provides a multitude of Transition Handoffs , the patient sits in their stool searching for the bed alarm looking for help. There should be help on the way !The teams keep growing. We continue to add more “7 on 7 off” doctors in search of life work balance. A few more well structured handoffs and a week off with no need to worry about medicine.Maybe someone will call time out to the hospitalist movement and set it on a new path. I wonder if House would have answered the bed alarm. Too bad he is leaving.

i work in a large academic medical center. here is my take on disruptive (physician) behavior:

some incidents are just plain uncalled for and need to be responded to appropriately. shaming, blaming, passive aggressiveness, and undercutting are bad, also throwing instruments or threatening residents with heavy equipment, laying hands on people, etc.

some incidents are fatigue-generated bc physician is exhausted. i am cranky when tired, are you? esp. when my job doesn’t give me time to eat or relieve my bladder. physicians’ jobs need to be made more do-able.

fear is a huge component in toxic behavior, and i believe that many women have a hard time realizing this. men are by and large more familiar with the fear-leads-to-toxicity relationship. fear for patient and/or consequences of mistakes is powerful, and mistakes in medicine can be severe.

abruptness often comes from not wanting to engage in endless negotiation and explanation under severe time pressure. this one will get worse as young people who have been raised to have everything explained to them and who expect to argue as equals enter the system more.
i encouraged a new assistant to find another job bc she needed constant explanation, always had better ideas, and required constant reassurance and rewards. i had neither the time nor the inclination to satisfy her needs, hired an older assistant and things are good. eventually this will not be possible.

i regard the house of god/ben casey attitude as a possible red flag that a physician’s documentation is in poor shape, and it is a good indicator. probably works 90% of the time.

While violent or threatening behavior is truly deplorable my local hospital used patient chart documentation of errors and poor clinical decision making on his patients by hospital employed physicians and staff to try and force certain physicians to therapy for ” disruptive” behavior. They said the documentation was inflammatory when in fact it recorded the events and the physicians’ attempt to be advocates for their patients.

Unruly physically threatening behavior usually is apparent before the doctors entrance into medical school. Poor screening of medical school candidates, Lazy or absentee supervision by academic physicians at residency programs and fear of litigation lead academic leaders to pass the problem on rather than identify it before you graduate and license the individual. Then hospital administrations, using employed physicians paid and influenced by them, use disruptive physician programs to silence physicians complaining about intolerable service and care provided by the institution. Its a dangerous slippery slope.

House was a sociopath and a fictional character. He was no more believable than the characters on the daily mid week soap operas. His behavior and actions were well off the bell shaped curve. In 34 years of practice I have seen no one that pathological involved in any aspect of patient care. To use fairy tales as an analogy is certainly a great way to divert the publics attention toward more bureaucratic regulation and away from the problems of institutional care created by the self serving regulatory bureaucracy.

It is natural that things were a little bit exaggerated in the name of a good spectacle but at least the TV program inspired many people to pursuit a medical career and now more doctors prefer multidisciplinary approaches. I heard the House MD production team used a symptom checker called ESAGIL (http://esagil.org) for medical diagnosis.